Provider Demographics
NPI:1164199410
Name:JACKSON SUPPORT SERVICES
Entity Type:Organization
Organization Name:JACKSON SUPPORT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LATASHA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-846-5650
Mailing Address - Street 1:532 BUCKINGHAM PL
Mailing Address - Street 2:
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-6111
Mailing Address - Country:US
Mailing Address - Phone:619-845-5650
Mailing Address - Fax:
Practice Address - Street 1:532 BUCKINGHAM PL
Practice Address - Street 2:
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-6111
Practice Address - Country:US
Practice Address - Phone:619-846-5650
Practice Address - Fax:619-846-5659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-25
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No251E00000XAgenciesHome Health
No253Z00000XAgenciesIn Home Supportive Care
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness